Sunday, November 22, 2009

Since we seem to be in an ethics mood following that last post, let me put up this one up. It's a case that's bothered me for over 15 years. I know this is a change from my usual bitchy humor, but what the hell.

Let's take the Way-Back machine to the early 1990's. Dr. Grumpy is a 3rd year medical student, doing a 6-week surgical rotation at a VA Hospital in the heartland. Please remember, I am at the level of a peon (or lower) and therefore have no input in the case.

Patient is a 75 year old man, who, to use a medical term, is sick as shit. Multiorgan disease. Metastatic cancer. Sepsis. On dialysis. He has gigantic bedsores down to muscle and bone on his back and butt (this is why surgery was involved, to debride these horrifying things). He's suffering terribly. He's had a stroke, and can't talk or understand speech.

He has a wife, 20 years younger than him, who he married 2 months earlier, when he was still ambulatory. She is the POA. I know nothing about how long she'd known him previously. If he had kids, I don't remember, and I never saw any.

This poor man needs to die. That is blunt, but true. He will never have a meaningful quality of life, ever. He is suffering, and we can do nothing to really comfort him. We can't give him Morphine for his pain, because that might shut down his breathing and make him die because...

He has a large life insurance policy, the details of which I don't remember. BUT I do remember one thing very clearly, because it was a big topic of discussion. The wife ONLY gets the money IF the patient dies after June 1. If he dies before, she gets nothing. Maybe his unknown kids would get it before then, I just don't know. Please remember this was over 15 years ago, and I don't remember a lot of the details.

So it's now February 24. Over 3 months left until the wife can collect money. And the patient is a full code. He codes at least once every 2-3 weeks. Each time the medicine team runs in, shocks him, forces him to stay alive. Forces us to continue cleaning these horrible gaping wounds down to the bone. And, from a financial viewpoint, his care is likely costing $5,000 to $10,000 of your tax dollars per day.

And the wife won't let him go. She maintains that she loves him and can't live without him, and can't bear to let him die. Maybe that's true. Or maybe not...

I don't know how the story ends. I went off rotation, and to another hospital, at the beginning of April.

Sorry to be a downer, but I thought it would be interesting to toss out an ethics case after the responses to last night's post.

29 comments:

Wow, sad case. You can understand the woman's thought process...she "deserved" the money because they had paid for the insurance with no idea that this catastrophic illness would occur but just because something happened "sooner" rather than "later," she would not get her pay out. Of course, all insurance is a betting game...she just lost on this roll of the dice. Too bad she was not going to have to pay for the $10K/day out of the insurance $$: might have let him go sooner.

UGH!!! I've seen that too many times, too. And from what I've seen, even having an 'ethics commitee' en suite doesn't really help...All we can do is let it go ~ the option is to go crazy (like slapping some family members upside the head, or going home and blasting our brains out...

Too bad more people do not think about filling out an Advanced Directive. Then the decision would be their own choice. If that woman really did "love" him, she wouldn't want him going through that. Both my husband and I have a living will and advanced directive filed with our primary care physician and a copy at home.

No one wants to let go of a loved one, but if you are holding on for your own selfish reasons when the person clearly needs to pass from this life, you have serious issues. You are right Dr. Grumpy, he needed to die. I hope he was able to without having to wait too long.

And the wife? Seems like a gold digger...could be wrong, but that's how it seems.

As a wife 15 years younger than my spouse, if my husband was ready to die I wouldn't ask for heroic measures. Palliative care to keep him comfortable, but no more. (He has an advance directive and DNR.)

Money can be nice, but it's not worth it when it comes at the expense of a loved one suffering.

This need we have to prolong life at all costs, when there is clearly no hope of recovery, is pointless and dangerous.

Allowing people to die when they should is so much less traumatic, for both patients and the people who love them. Letting my maternal grandpa die at home meant that, the night before he died, my cousins and I carried him to his room, we tucked him into bed and nestled the dog against him. I kissed him goodbye, and slept in the bedroom next to him. A home-care nurse made sure he was not in pain. It was sad, but peaceful, and I knew it was right. I'll always be grateful for that.

that is quite horrifying really. Basically, if you love someone you will let them go - stop all the suffering and just say "goodbye". Clearly - as in your other post - there are those that cannot bear to face up to the reality of what is happening - but sometimes what can you do except gently point out the true reality of what is going on.

I'm actually writing my paper for Ethics for Health Care Professionals right now! While I get that Life Itself is a Good (in the greek sense) I cannot imagine that any sensible human being would think keeping a man in terrible pain for months was a GOOD idea.

I'd like to think that this would not happen anymore in a VA hospital. Not sure that is true though.In the early 90s I was a new grad nurse working on a med-surg floor at at VA. We had a demented total care patient whose wife refused to allow him to be transferred to an extended care facility - reportedly because his income would then go to pay for the SNF and not to his wife. He lived on a med-surg ward for three years. The chief of medicine rotated on as attending, realized he'd been on her service years prior, and had him sent to a SNF.How I wish that ethics committees had real power (and sometimes wish they had chutzpah), but alas, they are usually not helpful. CardioNP

Working in nursing homes before pharmacy school was probably one of the best unforeseen decisions I ever made. (I came from a very hearty healthy lot of mostly 'Spartan' women who didn't complain about anything, so had 'wanted' to see what kinds of medications I might be dealing with in pharmacy.) As a nurse aide I saw bedsores beyond belief, patients that appeared nearly frightened out of their minds, and patient's family involvement or non-involvement. The first couple weeks I worked I came home and cried. After a while I figured I had a few decent morals (and was slowly developing an understanding of ethics). I rationalized that while I was working at this job, I may as well do the best I could, and gradually came around to the idea that care with dignity was the least I could do, as if each patient was my own memere. (By the way, even the 'cleaning ladies' have a feel for whether a patient is being cared for by family members..., not just peon med students.)

Working in health the last 35 yrs, I'm occasionally still surprised there are people my age without inherent understanding of a concept that the basic issues in maintaining a quality of life depend on the individual experiencing them, and not clearly defined in a textbook.

The 'wife' in the case was clearly banking on opiates relieving all her financial benefactor's pain, or maybe just doesn't care.

I find it difficult to use terminology of 'doesn't care', because inclination to believe the attitude is rather a lack of responsibility or information that individuals can be significantly helpful. (This is where I think that owning a dog is a worthwhile experience for kids.)

In discussing family involvement, too, I have occasionally run into the situation where crazy family members run interference in an elderly relative's care and end up doing much more harm than good in the outcome, and wonder why the physician didn't come right out and tell the crazy member to 'cool it' when bugging the MD to ask for this or that consult or this or that therapy.

Does the doctrine of "dual effect" apply in the US.? Basically, this a therapeutic exemption to the usual rule of law that if you do something realising that death is a possible consequence then if the person to whom you have done that thing dies in law you have intended that death. The doctrine of dual effect is that if the physician's primary intention is to treat pain and suffering then he may do so even if a consequential effect is to shorten the patient's life. See Smith JC. A comment on Moor's Case" Crim. L.R. 2000, JAN, 41-44.

If there was ever a case for the morphine syringe driver or the fentanyl patches this would be it. To Quote Sydenham: "Among the remedies which it has pleased Almighty God to give to man to relieve his sufferings, none is so universal and so efficacious as opium".

Agree with those that have pointed out the effectiveness of DPAHC's and Living Wills ~ and believe me ~ mine is QUITE specific!! The problem is in getting PCPs to discuss end-of-life care issues... that's why I was so flippin' pissed at Twit Palin's 'death panels'.

Ladyk73 ~ I must respectfully disagree with you on the 'slow code' (or 'chemical code only') scenarios... All those do is waste time, money, and give families false hopes...

response to me...twit palin doesn't have death panels. those are obama's. we can deny them or we can call them by other names but the result is the same. not that i think a death panel would be a bad idea. if the family is not acting rationally and the medical staff is unable to shine the light of reason on the situation for them, then somebody has to make the call. of course, if the payor cuts off the funding the patient/family should be free to pick up the tab themselves.

I also find this very strange and sad. At the hospital I work at, in this kind of situation the resuscitation status becomes a medical decision - and not usually in the form of a "slow code", a family will be told that medical treatment is futile and the patient is not a candidate for ICU. It's so sad that this poor man suffered.

People talk, talk, talk!!! I don't care where you work or what you do. Be an MD or be a peon, or somewhere inbetween.

The wife sounded like a gold digger. Think about it , married him 2 months before he got sick. Hello, didn't she look under the covers? Didn't she care for him at all? They were married. She should have made sure, that he was well taken care of. Wonder who else got some money besides her?

When I was a 3rd year student on geriatrics I remember a case with a terminal, cachectic, metastatic cancer patient who had the "O" sign (big open mouth--- but stuporous, eyes nearly closed). The brother and sis in law asked my attending if they could keep him alive for 3 more days b/c they really needed his SS check! My attending said "you want to prolong his death so that you can cash his check?" They said "well yes". My attending had to leave the room b/c he told us he thought he'd punch him if he stayed.

I always thought that the solution in these hopeless cases is that a panel of doctors should deem the patient hopeless for meaningful recovery and futile and then we can continue care but ONLY if the family pays out of pocket. You'd see a lot more plugs pulled!

In your case you could have offered to let her take him home so she could lovingly care for him :)

i have seen in my practice as a nurse a physician write "DNR for humane reasons". whether or not that was legal or right, i don't know. it was a little different than this case, however. in this one, which in medicine we unfortunately see often, it can be difficult to determine the reasons for why the family does what it does, but it almost seems obvious here. on the other hand, he was ambulatory before they were married if i understand correctly, and they had just been married. she may have very well wanted him to live because she loved him. i'm not saying it's probable, but possible.

and to Nick C.--when the medical staff is so involved with a patient and the family, you find out many things about the history and family dynamics. some you'd rather not know, but the good comes with the bad. it seems we always find out more details from crazy family members, too.

This reminds me so much of the stories in the book "House of God," by Samuel Shem. Unfortunately, I think the US has waited too long to address & debate end-of-life issues. Even having worked in healthcare for 5 years (and having read broadly in medical literature), I didn't learn the specifics of hospice, advanced directives/living wills, etc, until medical school.

I had surgery this past summer, before which I filled out my own advanced directive. I'm only thirty-something, but I felt it was an incredibly important measure to take. Needless to say, the majority of my family--my father especially--freaked out. How dare I even consider the possibility of being incapacitated?! <--that attitude is precisely the problem. I personally don't believe you're ever too young to think about and decide what you want in such situations. Morbid? Perhaps. Necessary? Absolutely.

For anyone interested in reading/learning more about end of life issues, I highly recommend the following:

-books by Jodi Picoult-the aforementioned book House of God, by Samuel Shem-the case of Anna Pou, MD (physician in New Orleans during Hurricane Katrina who was sued by the state for her patient care during that time)-On Death And Dying, by Elizabeth Kubler-Ross, MD-anything regarding the history of hospice-for creating your own advanced directive/living will, Nolo Press books (http://www.nolo.com/)

When I was a new-ish Home Health RN I was seeing a patient who was s/p a major CVA, with a PEG tube, Foley, sand bed, and HUGE pressure ulcers. The gentleman also had no real cognitive function. He lived with his wife and adult daughter in the "old money" part of town. Found out from the stuff on the walls and talking to family that he was a retired General. The family was furiously set against Hospice, and wanted "everything" doe, but it had to be at home, not in a SNF. Well, as has been previously mentioned, when a patient goes to a SNF so does his or her check...but to make it worse in this case, the emaciatated breathing corpse that used to be the General had opted NOT to sign up for survivor benefits on his heftly military retirement. ERGO---when his heart stopped, so did ALL the money. When we moved to another state this man was still technically alive.....and Medicare was footing all the bills so wifey could continue to live in the manner to which she had become accustomed.

Welcome to my whining!

This blog is entirely for entertainment purposes. All posts about patients may be fictional, or be my experience, or were submitted by a reader, or any combination of the above. Factual statements may or may not be accurate.

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